Use of Polyglycolic Acid Mesh in Extreme Preterm Premature Rupture of Membranes (PPROM)

Occurring before gestational week 26, extreme Preterm Premature Rupture of Membranes (PPROM) is one of the important problems of obstetrics that may involve serious complications for both the mother and the baby [1]. PPROM is seen in 0.4-0.7% of pregnancies and increases fetal death risk by 1.2% [2]. The fetal adversities it may cause include neonatal sepsis and respiratory distress syndrome. Seen in 13-60% of the cases, the maternal complications are chorioamnionitis and intra-amniotic infections. Postpartum infections and endometritis may occur in 2-13% of pregnancies involving PPROM [1]. Other than antibiotherapy, steroid administration and expectant approach, there are no options in the treatment of PPROM today. Our goal in this study was to prolong as much as possible the pregnancies of the 3 patients who had spontaneous PPROM between gestational weeks 22 and 26, which are at or below the viability limit, and in this way to minimize the fetal morbidity and mortality associated with such pregnancies and extend the pregnancy to the most advanced weeks attainable.

solution (TISSEEL Lyo) was heated in a Fibrinotherm device to be used for fi xing the PGA mesh. Having been used with success in the treatment of CSF escape before, this system consisting of a bioabsorbable product and fi brin glue was used in 3 extreme premature membrane rupture cases to stop the amniotic discharge that clogged the cervical os. No tocolysis was administered to the patients. Each patient was given detailed information about the procedure and their informed consents were obtained.

Implementation of the technique
An oval piece of PGA (neoveil, gunzo, Kyoto, Japan) mesh was cut in a way to cover the cervix and the fi brin glue was applied to its edges to fi x it on the cervix (Figure 1). PGA is a homopolymer weighing 100,000 Daltons which hydorlizes into hydrogen and carbondioxide with the help of pyruvic acid. offspring with 8 apgar scores was delivered. The newborn died a week later.

Case 3
PPROM developed in a 33-year-old G1 patient at week 24 and day 2. She had vaginal amniotic leak. In her ultrasonography, her biometric measurements were compatible with her gestational week and her amniotic fl uid decreased. As in the other patients, she was administered betamethazone and antiinfection therapy. The patient gave birth at her gestational week 28. The baby is still alive with no morbidities. After routine examinations, all the patients were administered polyglycolic acid mesh and fi brin glue. Prophylactic antibiotics were given to them during this time. They were monitored with ultrasonography twice a week. Increased amniotic fl uid was seen in ultrasonography in all patients. The patients were checked with pads and no further fl uid discharge was seen.
They were monitored for fever everyday and for hemogram and CRP (C reactive protein) values twice a week. After they reached 24 week of gestation, they were administered 12 mg of intramuscular betamethazone twice in a 24 hour interval.

Discussion
PPROM is defi ned as a rupture of membranes occurring before gestational week 24. Its prevalence is less than 1% of all pregnancies [3][4][5]. The most common risk factor is Group B streptococcal infections. Its more frequent occurrence in white and Hispanic women indicates the importance of ethnic background. Its other causes include urogenital system infections, exposure to diethyl stilbestrol in the intrauterine period, maternal weight, uterine distension (multiple pregnancy, polyhydramniosis), gestational diabetes, cervical cerclage, smoking, a history of preterm labor in previous pregnancies, iatrogenic membrane rupture during amniocentesis or cervical cerclage, and antepartum hemorrhage [6]. Its major neonatal morbidities are pulmonary hypoplasia, bronchopulmonary dysplasia, contractures and infections [7,8]. The most common maternal complications include endometritis, placental abruption and retained placenta. Less common maternal complications are sepsis and maternal death [9][10][11]. A study stressed, considering its maternal, fetal and neonatal outcomes, the importance of making a good decision when planning for treatment [12]. Studies in recent decades have expressed that neonatal outcomes are partially a little better. However, this is thought to occur due to different study designs in different sites, gestational age during PPROM, different inclusion criteria and different treatment protocols [4,13,14]. In their study investigating the fetal and maternal occurred at a rate of 64% and contractures at a rate of 58% [15].
In our series of cases, only 1 baby out of 3 pregnancies survived

Conclusion
PPROM is known to increase morbidity and mortality at a high rate. The most important problem in the management of PPROM is the morbidity developing in living babies. Given that, our goal should be to minimize fetal morbidity. We managed to prolong the gestational period up to one month in extreme PPROM cases. Although this time span is not very effective for a 22-week PPROM case, it should be considered as a very meaningful period of time for more advanced weeks.
In our study, none of the lost babies died due to infection and one of these newborns still continue to live as a healthy baby. The other two babies were lost as a result of extreme prematurity. Therefore, by practicing this treatment method in more advanced weeks in broader series, pregnancies can be prolonged into weeks ahead and better neonatal outcomes can be obtained.